Regent RCM

Managing Overpayments

Vice President of Managed Care Andrea Woodell negotiates payer contracts on behalf of Regent RCM’s clients, attaining aggressive gains for both existing and new partners. For 20 years, Andrea has negotiated on behalf of health care providers and professionals, working in tandem with business offices to enhance collections. In this blog post, Woodell offers insights on how best to manage overpayments from payers.

Contrary to popular belief, overpayments are not welcome and can put a burden on billings and collections. “Surgery centers don’t want to be overpaid,” advises Andrea Woodell. “The accurate payment amount has to be determined and the difference has to be agreed upon and returned to the payer. It’s time consuming and costly to keep touching the claims.”

Woodell stresses to clients that overpayments are critically important because many of the contracts have language stating that if they are overpaid it should be reported to the payer and paid back within 30 days. Even if the payer doesn’t request a refund, the majority of contracts require a refund be issued.

Conversely, not refunding habitual overpayments can quickly add up to hundreds of thousands of dollars. Many states allow payers to go back three to five years to collect overpayments. A payer may hire an outside auditor to look for cash in the form of overpaid claims, typically attributed to the payers’ inability to administer their own contract terms accurately. No one wants to be on the receiving end of a letter stating they owe $250,000 back to Payer xyz and recoupments will begin in 30 days. “It’s a manpower intensive business,” said Woodell, “and when ASCs lack expertise or staffing, or don’t have the protocols and processes in place to manage overpayments, it’s a lose-lose situation.”

  1. Determine if the overpayment request is legitimate – “When a payer requests a refund, do your research,” advises Woodell. “Initial research is required to determine if the refund request is legitimate.” It is not uncommon for a self-funded group to hire a repricer who in turn requests a discount or refund not contractually supported. They just ask, and a facility with inexperienced staff may refund the monies accepting the request as legitimate without performing their own due diligence

The refund request may be appealed by the facility if a payer sends it because a claim was missing required authorization for service or was deemed medically unnecessary. In such cases, the center can provide supporting documentation to the contrary.

If the refund request is considered legitimate, Woodell summarizes the next two steps centers should take prior to returning overpayment:

  1. Determine if the overpayment amount is accurate – Start by calling the payer. “Ask the payer to explain how they determined the payment amount,” said Woodell, “then find out if the payer processed the claim correctly.” While we have made significant improvement in cleaning up the language in fee schedules, many still have verbiage that is confusing, misleading and open to multiple interpretations.
  2. Get the correct paperwork – If the payer confirms that they overpaid through a written request, and your contract supports their logic, then send the refund back to the payer within the appropriate timeframe per contract requirements. “Whether we’re dealing with clients, patients or payers, open communication always goes a long way.”

Determining overpayment is one issue, but according to Woodell, getting to the root of the matter is another. “I am currently working with a center that has overpayment concerns. I am modeling what they are being paid, what contractually we think they should be getting, and then working with them to get a new contract that tightens up the language and absolves them from recoupment,” said Woodell.

While there are consequences for non-payment, Woodell maintains that refunds don’t have to be difficult. “It’s all about establishing protocols,” added Woodell, “and at Regent RCM we have them in place for overpayment to ensure that we stay compliant and continue to foster long lasting relationships with payers.”

Is your center struggling with overpayments? Regent RCM can help. Call us today 312-882-7228.


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How Regent RCM Leverages TRICARE Expertise to Maximize Reimbursement

Regent RCM has developed a high level of TRICARE expertise, another core competency that sets Regent RCM apart from other revenue cycle management (RCM) providers. This unique experience offers ambulatory surgery centers (ASCs) valuable knowledge to maximize their reimbursements.

TRICARE, the health care program for uniformed service members and dependents, is managed by the Defense Health Agency and covers nearly 9.5 million beneficiaries around the world. TRICARE serves active duty, retired and Guard/Reserve service members and their families, and benefits and plans vary widely depending on the beneficiary category and the region. Other insurance carriers also process claims for TRICARE, which adds to the complexity of billing and collecting payment for health care facilities.

“It’s a complex process to understand  – determining how to bill appropriately, how you should be getting paid, what they should reimburse you, and what’s included in reimbursement,” said Leslie Favela, revenue cycle supervisor at Regent RCM.

Favela explained that many ASC administrators are under the wrong impression that TRICARE won’t pay for certain procedures when billed, which makes centers reluctant to accept TRICARE patients in the first place. “This is an unfortunate misconception,” said Favela. “TRICARE offers set reimbursements for many procedures, but it is necessary to understand the intricacies of billing the claims correctly in order to maximize reimbursement.”

Regent RCM has conducted extensive research into TRICARE: How the billing process works, what to charge, and what procedures are allowed and not allowed. Importantly Favela notes, TRICARE rates change each year on November 1. “Regent RCM makes it a priority to maintain the most up-to-date reimbursement information as part of our team’s standard process,” explained Favela. “We pride ourselves on having an expert understanding of TRICARE expected reimbursement, which we then leverage to get the maximum payments for our ASC clients.”

TRICARE has an enormous reach, and Regent RCM’s proficiency in reimbursement is highly beneficial for centers located near military bases or serving uniformed patients and their families.

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Regent RCM Health Care Industry News | October 2015

Each month Regent RCM explores the top news and headlines affecting the health care industry.

This month in the news: ICD-10 has had a smooth rollout thus far, surgery centers are pressured to reduce their costs while maintaining quality of care, reimbursement rates for hospital outpatient departments are rising faster than ASCs, and consumers demand more transparency on price and quality of services.

ICD-10 Transition Smoother than Expected

Contrary to reports that 25% of physician practices weren’t ready for the October 1, 2015 transition to the new ICD-10 code set, Forbes reports that the rollout has been smooth thus far. Sid Herbert, head of the ICD-10 implementation team at Humana (HUM) echoed that finding by stating, “We are about ten days into this and already have 50% of our claims coming in. Almost everyone who is submitting claims is getting it right.” In an effort to support industry partners and continue the seamless transition, Regent RCM coding partner, Surgical Notes, MDP, LP, provides helpful ICD-10 coding tips, found here.

Surgery Centers Pressured To Reduce Costs and Maintain Quality

No health care provider is immune to the pressure to lower the cost of delivery while maintaining quality. Click here to read how Carolina Neurosurgery and Spine Associates make a case for the ability of surgery centers to deliver cost savings while upholding quality, safety and ultimately, patient satisfaction.

Outsourcing RCM frees up clinical and front-office staff to focus on quality of care and center functions that can increase patient and surgeon satisfaction. If you are exploring RCM options, click here to speak with a member of the Regent RCM team.

Reimbursement for ASCs vs. Hospital Outpatient Departments

Fierce Health Finance recently reported that reimbursement rates for hospital outpatient departments are rising faster than rates for ambulatory surgical centers (ASCs). Click here to read more and join our ongoing conversation via Twitter @RegentRCM.

Consumers Demand More Transparency and Push for Better Data

As reported by Crain’s Detroit Business, “The movement to high-deductible health insurance plans — designed to control costs and put more decision-making in the hands of patients — has saved employers billions of dollars, but it has also put pressure on the health care industry to become more transparent on the price and quality of its services.”

Automated RCM allows ASCs to tailor billing to include relevant, customized details to overcome patient satisfaction barriers and ensure that your ASC delivers the level of transparency that your center needs and your patients expect. Contact Regent RCM to learn more.

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Regent RCM Healthcare Industry News | August 2015

Each month Regent RCM explores the top news and headlines affecting the healthcare industry. 

This month in the news: States with high percentages of uninsured people drop this year, many physicians lack confidence in ICD-10 with the deadline approaching, and ASC Focus magazine reminds ASC’s to confront their financial and management concerns.

States With the Highest Percent of Uninsured Population Drop in 2015

In the U.S., the amount of people who are uninsured continues to drop in most states. The ten states with the most uninsured people in 2013, many around 20%, have dropped significantly with the percent of uninsured in 2015 ranging from 6% to 11%. Arkansas and Kentucky continue to have the sharpest decrease in uninsured rates since new healthcare laws in 2014. Most states have expanded Medicaid and established a state-based or state-federal partnership and the states that have embraced the multiple parts of health law continue to see the most improvement. To read more on the uninsured rates, click here.

Physicians Lack Confidence in ICD-10 with Deadline Approaching

With the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) deadline approaching, new data suggests that many physicians lack confidence in ICD-10. ICD-10 is anticipated to be severely damaging with claims disruptions, claim denials, etc. This may cause physicians to use personal funds to keep their practices running or go into early retirement. A small 10% of physicians state that they are “very confident” that their practice is ready for the ICD-10 deadline. Click here to read more on the lack of confidence in ICD-10 or click here for tips to accelerate your ASC’s ICD-10 preparation.

Overcome your ASC’s Biggest Financial and Management Challenges

ASC Focus magazine reminds ASC’s to confront their elephants, or the financial and management concerns that go along with providing the highest quality care for patients. These concerns include reimbursement, cost containment, increased regulations, management and patient education on ASC benefits. Quality care and expense monitoring for cost containment are just two of the ways ASC’s can confront their biggest challenges. Click here to read more on confronting ASC concerns or click here for tips to ensure an accurate and timely billing process for your ASC.